Gaps in sexual health content of healthcare professional curriculum: a systematic review of educational interventions

Background Sexual health care, including assessment and patient teaching, is part of comprehensive patient care. Health professional (medical and nursing) students’ education in sexual health lacks uniformity in content and assessment skills. Objectives The current systematic review aimed to assess sexual health educational curriculum for health professional students regarding the educational content, duration, and evaluation of these educational interventions. Methods This systematic review followed the preferred reporting guidelines for systematic reviews. A comprehensive search was conducted between May–August, 2023 across four databases (PubMed, Scopus, CINAHL, EMBASE), outlining 614 sources. Following the screening process, 36 educational intervention studies were deemed eligible for inclusion. The quality assessment of these studies was conducted using The Effective Public Health Project tool, which was found appropriate for evaluating this type of research. Results The studies had a global representation, with most studies conducted in the US. Limited nursing educational interventions were found. Three main categories emerged from the analysis of the educational interventions: one-time interventions, workshops, and semester courses. These categories differed in terms of their duration. Upon evaluating the educational intervention programs, it was found that the majority relied on participant self-reporting, while only a few included objective evaluations. Conclusions This review revealed inconsistencies in educational content for healthcare professional students and may impact their clinical skills, particularly in sexual health. The variation in content, duration, and evaluation methods created challenges in assessing the interventions. The lack of standardized sexual health education highlighted a significant gap, raising concerns about students’ ultimate proficiency in this area. Bridging this divide is essential by integrating comprehensive sexual health content and assessment skills into the health professional curriculum.


Introduction
The World Association for Sexual Health (WAS) emphasized sexual health (SH) as a fundamental right of every patient [1].Incorporating SH into a patient's overall well-being has been identified as an essential approach to delivering comprehensive health care and promoting overall health [2].Moreover, it was considered an integral professional responsibility within health professional's practice [3] and basic/advanced education [4].The sexual health assessment (SHA), positioned as a primary step of the health evaluation process, serves as an informed framework for addressing SH issues [5].Recognizing the integrated relationships between SH and all dimensions of life, a SHA allowed identifying existing or potential problems related to sexual well-being and potentially influencing the patient's and family's quality of life [5].The results of a SHA enabled health professional students to develop a personalized treatment approach that aligns with the patient's needs and preferences.SHA demanded a constructive perspective, encompassing positive attitudes, knowledge, and a proactive approach to initiate a conversation about SH [1,6,7].
The literature suggested that many healthcare providers lack the education and professional skills to address SH issues effectively.Studies such as the 2009 survey of American medical students [7] and the 2020 Danish national survey of health professional students [8] highlighted the persistent need for professional sexual health education (SHE) focused on acquiring SHA skills in the curricula.Students recognized the importance of SHA for patient health and well-being but also expressed a lack of appropriate training in this area.In studies that overall included over 1000 health professionals from diverse disciplines (medical and nursing), students report concerns about their unpreparedness regarding SH skills.Furthermore, the absence of SHA education in healthcare curricula can impact the ability of students to address SH issues in their future professional practice [9][10][11][12][13].
An SHA described as a part of a comprehensive health history, requiring integration of questions about SH.In order to conduct a SHA, it was essential to have relevant knowledge and communication skills [5,14].The National Coalition for Sexual Health (2021) recommended considering the following six aspects, the 6 P's, during the patient's SHA: partners, practices, past history of STI(s), protection, pregnancy and fertility, and P plus, which include pleasure, problems/dysfunctions, and Pride-LGBTQ issues [15].One of the popular models for discussing sexuality with patients is the PLISSIT model [16].It provides a delineated approach, beginning with introducing the topic by obtaining the patient's permission to discuss personal SH.
Professional experts for undergraduate medical education agreed that integrating the principles of SHA (knowledge, attitudes, and skills) should be a mandatory component of SHE for professional practice [17].Principles of SHA and 6 Ps' should be integrated into the curricula as part of the essential first-year skills for assessing the SH of the patient.The second-year curricula should focus on more advanced SHA skills, such as understanding the impact of various diseases on SH function [17].Though specific recommendations for studying SHA are not offered, the importance of having an objective structured clinical examination (OSCE) at the end of the first year and a theoretical summative exam at the end of the second year as a measure of the effectiveness of the curriculum was highly recommended [18].While these recommendations were intended for medical students, it is essential to recognize their significance for all health profession students directly involved in patient care.It is important to note that in the context of nursing professional education, many SH topics are not included as compulsory content in the curriculum [10,11].This lacuna persisted despite detailed information on SHA steps in nursing textbooks [5].
The impact of SHE curricula on improving the healthcare providers' ability to address patients' SH has been described in the literature [19,20].A review of educational intervention studies published between 2002 and 2020 contains 11 studies that found evidence supporting the effectiveness of SHE in improving knowledge, attitudes, and skills despite variations in intervention duration and educational content [20].However, only one study included senior nursing students, while the intervention curricula in the other studies targeted healthcare providers who had already graduated.Furthermore, the findings indicated significant variation in the duration and content of the interventions, with the majority not focusing on skill acquisition [20].
In contrast to previous results, another systematic review included 11 educational intervention studies in which the intervention focused on training SHA skills [19].Only two studies used actual evaluation measures to examine training effectiveness on improvement in SHA actual performance (OSCE and simulations).However, the performance observed following the intervention was tested under laboratory conditions and not with actual patients.In addition, only one study measured the actual performance by asking the patient whether they were asked about SH.The rest of the studies examined the effectiveness of the intervention by participants self-reporting.It is important to note that SHA skills in these studies mainly focused on assessing risk for sexually transmitted diseases (HIV, AIDS, STI) and did not include comprehensive SHA and communication skills [19].In addition, the quality assessment level of the studies included in the systematic review was suboptimal due to differences in research objectives, evaluation metrics, and the usage of varying questionnaires.Finally, similar to previous results, the interventions in this systematic review included only medical students or interns, with no mention of nursing students [19].
The present systematic review aimed to identify SH educational interventions and evaluations of these interventions designed for health professional students.The review intended to analyze these programs by examining their content, focusing on SH education, and investigating the taught frameworks or courses.It seemed to determine whether SHA was included and, if so, what assessment principles (knowledge, attitudes, and skills) were incorporated as educational objectives.The review also aimed to assess the duration of these educational interventions and evaluate the methods used for assessing SHA principles, presenting self-reported data vis a vis actual performance in clinical settings.

Searching strategy
The current systematic review followed the PRISMA guidelines for reporting systematic reviews [21].The research team followed a predetermined protocol based on PICO strategy and inclusion-exclusion criteria.Inclusion criteria encompassed intervention studies employing a pre-post intervention research design, focusing on SH education tailored for nursing and medical students.The inclusion criteria were peer-reviewed educational intervention design published in English between 2005-2023, with SHA educational content.The search was conducted across four databases (CINAHL, EMBASE, PubMed, and Scopus) with the assistance of a librarian.The search was conducted between May and August 2023 and included 614 studies transferred to the continuous screening phase.
The following search terms were used: TI ("Medical Student*" OR "Nursing Student*" OR "Health Professional Student*" OR "Medical Studies" OR "Nursing Studies") OR AB ("Medical Student*" OR "Nursing Student*" OR "Health Professional Student" *" or "Medical Education" or "Nursing Education"), TI ("Sexual Educator*" OR "Sexual Health") or AB ("Sexual Education*" or "Sexual Health" or "Sexual health assessment" or "Sexual health history"), TI OR AB curriculum.MESH or TSEZARIUS were used in relevant databases.

Study selection and data extraction
During the study selection process, ZOTERO software was utilized for source management and duplicate identification.After removing duplicates, 297 studies were transferred to Rayyan software for sorting [22].Initially, articles were screened based on their titles and abstracts, and only those aligning with the inclusion criteria (n = 79) were included in a second screening involving detailed reading.Eventually, after rigorous assessment, 36 articles meeting all criteria were included in the extraction stage (see Fig. 1).All phases of the screening process were independently conducted by two researchers (NB and AWW).The studies that presented conflicting decisions of the original two researchers were deliberated upon in a discussion involving the third researcher (SSK).Articles were included or rejected from the systematic literature review only after a consensus was reached through mutual agreement.
Data were extracted from the included studies based on the following criteria: study information (including the authors, year, and country of publication), study design, and target population.Information about sexual health education duration, content, assessment principles, and evaluation was offered.

Quality assessment
The Effective Public Health Project (EPHPP) tool developed by Thomas et al. (2004) was utilized for quality assessment of studies included in the systematic review [23].This tool has been extensively used in the literature and was considered valid for determining the quality of interventional research designs [24].Each study was assessed based on the EPHPP tool's seven components: selection bias, study design, confounders, blinding, data collection methods, intervention integrity, and analysis.In addition, the overall quality of each study was rated using a three-level scale (low, medium, and high quality) [23].Two researchers (NB and AWW) initially performed an independent quality assessment.Subsequently, the findings were shared with the third researcher (SKK), who compared the results obtained by the two researchers.Finally, any discrepancies in the results were resolved through discussion and agreement.

Intervention types
An analysis of the educational interventions revealed three main categories, namely one-time interventions (n = 9), workshops (more than 1-time intervention) (n = 20), and semester courses (n = 6) (see Table 2).Regarding one-time activities, most interventions (n = 7) concentrated on enhancing the SH of the LGBTQ population [29,30,33,35,40,43,59].In two other studies, the educational interventions content focused on addressing particular issues, such as sexual violence [58] and sexually transmitted diseases (STD) prevention [53], with a SHA, adapted to the specific curricula content.There was no report on which principles and models were utilized to conduct a SHA in these training programs [53,58].The last study [54] centered on imparting clinical skills for conducting genital exams on both men and women.Again, the study solely focuses on practicing the technical aspect of the skill without incorporating an evaluation of SH.
In the second category of educational interventions, 20 workshops were identified.Of these, only three studies utilized the PLISSIT model [16] or 6P's component [15] for SHA.SHA in these studies also focused on specific educational topics [26,55,56].For instance, SHA was taught according to the PLISSIT model [55,56] yet specifically tailored for the rehabilitation department [56] or dermatological and rheumatological assessment [55].In another study, SHA is based on the principles        ✓ female SP ✓ male SP ✓ transgender assigned male at birth SP Knowledge and communication skillsa significant change was found with a high effect size.However, the differences between means scores in the pre-postintervention were small, especially: Knowledge to discuss with young patients (from M = 3.59, SD = 2.19 to M = 1.93,SD = 1.17 of the 6P's, but there was no reference to the PLISSIT model [26]. The remaining workshop interventions (n = 17) incorporated SHA as part of the general educational topic, though the PLISSIT model is not mentioned.For example, two educational interventions focused on assessing sexual dysfunction in men and women [25,57].Three others concentrated on women's sexual and reproductive health, including SHA for unplanned pregnancies, STDs, and pelvic infections [32,38,45], as well as SH in the elderly [48].Another two studies focused on oncological topics, with one study basing their SHA on the "Did you CARD her?" model [28].Another four educational interventions included SHA as part of their curricula, but SHA was not the primary focus, with no information on the PLISSIT model [27,46,51,59].Additional three studies focused on the SH of the LGBT population with no specific information regarding a model for SHA [34,51,60].Finally, two educational interventions dealt with sexual trauma and child abuse but did not provide specific details on SHA [31,36].
The final category of educational interventions included semester courses for "long-term training" (see Table 2).Of the four studies (n = 6), only one provided a comprehensive SHE curricula including advanced SHA skills, such as the effects of diseases/medications on sexual functioning [44].The educational content in this study covered the biopsychosocial components of SH but did not specify which SHA model was used.
In the other five studies, SHA is adapted to the interventional topics and restricted to assessing LGBTQ SH [37,39,42], sexual reproductive health [49], and sexual dysfunctions [41].

Duration of educational intervention
There was a wide variation concerning the duration of the educational intervention.For instance, the length of a one-time intervention curriculum ranged from a brief one-hour lecture [29,30] to extensive training that entailed four hours of hands-on practice [54].Most onetime educational intervention programs (n = 5) lasted two hours and utilized various teaching methods [33,35,43,58,59].Three studies did not report on the duration of educational interventions [29,40,53].
Long-term educational interventions were different regarding duration, ranging from courses lasting a semester [37,41,44] to one annual course [41,49] and a continual seminar without a precisely reported duration [39].These educational interventions were delivered in the context of health professional educational curricula or professional staff educational interventions.

Evaluation of the sexual health education curricula
Table 3 represents the analyses of SHE curricula (n = 11), including methods of evaluating the improvement in SHA performance following the intervention.Of these, eight studies revealed improvement in SH skills, but these findings were based solely on self-reports [25,28,34,37,42,47,54,55].Only three studies evaluated SHA using actual behavioral change [26,27,51].One study by Loeb (2010) described improvement in SHA skills in professional practice based on patient chart review.After the educational intervention, participants frequently asked about sexual practices, partners, and contraception [26].Another two studies [27,51] used an OSCE clinical examination and chart review to evaluate the education curriculum.The study results indicated significant behavioral change regarding SHA and patient education in general.However, participants from one study [27], experienced only one simulation focused on SHA skills.In contrast, in another study, the SHA was evaluated online without follow-up [51].

Discussion
The current systematic review evaluated educational interventional studies that included SHE interventions for health professional students.Specifically, the review detailed the duration of these educational interventions with SHA content (knowledge, attitudes, and skills).Additionally, the review explored how the educational intervention was evaluated, whether through self-reported measures or via an actual performance of SHA.Among the 36 articles, which constituted an international health professional student sample, few educational interventions in SH were found for nursing students.If at all, these SHE interventions focused mainly on senior nursing students.This finding aligns with the literature review [19], wherein most educational interventions aimed at addressing SH include graduate students, interns, or professionals' continuing education post-graduation.
The research findings corroborated the assertions made by Blakey and colleagues (2017) regarding the absence of comprehensive SH education for nursing students [10].Therefore, the researchers argued that this lacuna in SHE contributes to the lack of emphasis on SH matters in professional practice [10].Furthermore, these findings   shed light on the global insufficiency of adequate SHE provided to health professional students during their early years of study, contradicting the recommendations set forth by the World Health Organization [6].It is suggested that further research be conducted to examine the correlation between the omission of SHA in health professionals' curricula, particularly in the early stages of learning, and practitioners' inattentiveness to SH during clinical practice.Understanding that SHA is one of the essential competencies would encourage health professional education experts to integrate this content as suggested in the literature [9,12,13].This systematic review identified various SHE interventions that differed in duration, educational content, and teaching methods.Similar variability was also observed in other systematic reviews [19,20].Coverdale (2011) emphasized the importance of consistency in determining educational variables and the need for diverse research designs to enhance the quality of evidence [19].Our systematic review revealed differences in intervention variables and evaluation procedures.In addition, we noticed inconsistencies in research designs, as some studies lacked follow-up measurements, indicating the need for more rigorous evaluations in future studies.Similarly, our literature review uncovered diversity in the duration and content of educational interventions, consistent with the findings reported by Verrastro (2020) [20].These variations underscored the lack of standardization in SHE for health professional students.
The literature suggested integrating SHA with all curricular components, including knowledge, attitudes, and skills [5,18].This integrated approach offered a foundational framework for comprehending the various factors that influence SH in both health and disease.By employing the three principles of SHA, students can acquire knowledge and skills, develop a deeper understanding of their personal attitudes toward the subject, and cultivate a sense of professional responsibility regarding SH as an integral part of their practice [5,18].It has been documented that professionals can only proceed to more advanced SH skills after reconciling personal beliefs with professional obligations [5,18].
The current systematic review highlighted the variation in the content of educational intervention programs.For example, while many studies have developed interventions focused on the SH of LGBTQ populations and/or women's health issues, only a few interventions have incorporated SHA skills based on the comprehensive 6P'S model [15] and the PLISSIT model [16].This is unfortunate since these models provide a structured approach to discussing SH.Omitting these principles in most interventions or providing educational interventions that only cover specific aspects of SH may not foster a sense of comprehensive responsibility and dedication to the subject.Despite having positive attitudes toward the topic, students struggled to address patients' SH, as reported in the literature, while SHA was perceived as daunting [11].It is possible that establishing teaching standards for comprehensive SHA could provide a consistent foundation for professionals' sexual health education.Nevertheless, it is advisable to conduct future research to determine whether this standard fosters the health professional students' ability to initiate conversations about SH.
Finally, this systematic review reported different evaluation methods used to assess the effectiveness of SHE interventions.Only a few interventions included evaluating SHA in clinical practice.Instead, most of the programs relied on self-reported data, which may be affected by participant biases.As a result, it is challenging to draw definitive conclusions about the actual effectiveness of these interventions in practice.To address this issue, researchers recommend using an Objective Structured Clinical Examination (OSCE) for practical application, which has been identified as the most reliable way to evaluate curriculum [18].

Limitations
This systematic review had several limitations.First, valuable insights from similar studies published in other languages were missed by solely incorporating articles in English.This fact possibly limited the quality of evidence and the extent to which the findings can be generalized.Moreover, it is conceivable that some pertinent studies were omitted from our review due to using a predetermined search strategy.Furthermore, it is worth noting that only a limited number of studies centered on nursing students, suggesting potential biases in interpreting the results.The present systematic review did not explore cultural and socio-demographic factors that could impact students' attitudes and clinical abilities in SHA.Adapting programs requires tailoring interventions to cultural nuances and integrating content on cultural sensitivity within the curriculum.

Conclusions
Health assessment encompasses a thorough approach that enables the evaluation of patient's health from a biopsychosocial standpoint [5].This approach considers various aspects of an individual's life that can influence their well-being, including SH. Creating standardized SH education curricula and integrating vital SHA skills enables health professional students to acquire the necessary knowledge and capabilities for patient SH evaluation.This study highlighted a significant gap in SH educational intervention.Varied learning objectives, intervention durations, and curriculum methods posed challenges in evaluating intervention program effectiveness.Examining educational outcomes and establishing guidelines for comprehensive SH professional education, incorporating SHA skills, and extending it to all healthcare students involved in direct patient care, is crucial.

Table 1 (
continued) Acronym: a EPHPP Effective Public Health Practice, Quality assessment tool for quantitative studies: (degree of Q/A: 1-strong, 2-moderate, 3 -weak).Sources are presented in the table by year of publication; SH Sexual health, ED 2 Erectile Dysfunction, STI Sexual Transmitted Infections, e-PBL Online Problem -Based Learning, S-PBL Simulation-based Problem Learning, LGBTQ Lesbian, Gay, Bisexual, Transgender, Queer, DSD Difference in Sex Development -affected, HIV Human Immunodeficiency Virus, OSCE Objective Structured Clinical Exam

Table 2
Characteristics of the educational intervention curricula, presented by types: one-time intervention, workshop, semester course

Table 3
Evaluation of sexual health educational interventions